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Abstract

Background

In 2001, the World Health Organisation (WHO) recommended exclusive breastfeeding for
the first six months of life. The objectives of this study are to assess awareness
of the WHO recommendation among first-time mothers (women at 24 to 34 weeks of pregnancy)
and to explore the relationship between this awareness and mothers' intention to exclusively
breastfeed for six months.

Methods

This study was part of the Healthy Beginnings Trial (HBT) conducted in southwest Sydney,
Australia. We analysed cross-sectional baseline data of the trial conducted in 2008,
including 409 first-time mothers at 24 to 34 weeks of pregnancy. The mothers' awareness
of the recommended duration of exclusive breastfeeding and their intention to meet
the recommendation were assessed through face-to-face interviews. Socio-demographic
data were also collected. Factors associated with awareness of the recommendation,
or the intention to meet the recommendation, were determined by logistic regression
modeling. Log-binomial regression was used to calculate adjusted risk ratios (ARR).

Results

Sixty-one per cent of mothers knew the WHO recommendation of exclusive breastfeeding
for six months. Only 42% of all mothers intended to meet the recommendation (breastfeed
exclusively for six months). Among the mothers who knew the recommendation, 61% intended
to meet the recommendation, compared to only 11% among those mothers who were not
aware of the recommendation.

The only factor associated with awareness of the recommendation was mother's level
of education. Mothers who had a tertiary education were 1.5 times more likely to be
aware of the recommendation than those who had school certificate or less (ARR adjusted
for age 1.45, 95% CI 1.08, 1.94, p = 0.02). Mothers who were aware of the recommendation
were 5.6 times more likely to intend to breastfeed exclusively to six months (ARR
adjusted for employment status 5.61, 95% CI 3.53, 8.90, p < 0.001).

Conclusion

Awareness of the recommendation to breastfeed exclusively for six months is independently
associated with the intention to meet this recommendation. A substantial number of
mothers were not aware of the recommendation, particularly among those with low levels
of education, which is of concern in relation to promoting breastfeeding. Improving
mothers' awareness of the recommendation could lead to increased maternal intention
to exclusively breastfeed for six months. However, whether this intention could be
transferred into practice remains to be tested.

Trial Registration

HBT is registered with the Australian Clinical Trial Registry (ACTRNO12607000168459)

Background

Breastfeeding has a wide range of health benefits for mothers and children and is
a key protective factor against childhood overweight and obesity [1-4]. The current World Health Organization (WHO) recommendation for breastfeeding is
that all infants should be exclusively breastfed for the first six months of life,
and receive nutritionally adequate and safe complementary foods while breastfeeding
continues for up to two years of age or beyond [2]. The WHO recommendations have been adopted and endorsed by many countries including
Australia [3,5].

In Australia, a national survey found that in 2004-5, breastfeeding initiation was
88% [6], and similarly in the state of New South Wales (NSW), the percentage of infants "ever
breastfed" was 90% in 2001 [7] and 87% in 2003-4 [8] respectively. However, this high initiation rate of breastfeeding does not lead to
a high prevalence of sustained breastfeeding: only 16% of infants were exclusively
breastfed to six months and 29% were breastfed to 12 months [8]. The Health Department of NSW recommends the promotion of breastfeeding for all mothers
and infants to focus on extending the duration of breastfeeding to 12 months and exclusive
breastfeeding to six months, in particular among those mothers who are most socio-economically
disadvantaged, less than 25 years of age, or with less than a tertiary education [8].

Breastfeeding decisions and practices are influenced by multiple factors including
knowledge, attitudes and beliefs, as well as socio-cultural and physiological factors
[9-13]. However, results from research into determining these factors to date have been
very variable due to a lack of objective, reliable, valid and sensitive measures [9]. In developed countries like Australia, mothers who are younger (under 25 years old),
have less education, or are most socio-economically disadvantaged tend to have lower
rates of full breastfeeding, rates of initiation and duration of breastfeeding [8,14].

There is increasing recognition of the need to promote exclusive breastfeeding since
the WHO recommendation on exclusive breastfeeding for six months was made in 2001.
However, the impact of such promotion on rates of exclusive breastfeeding is less
clear [15]. This might be explained by a poor understanding of the breastfeeding recommendation,
and of knowledge, attitudes and practice about breastfeeding in the community.

Research has repeatedly found that women's pre-birth breastfeeding intentions are
a good predictor of the actual duration of breastfeeding [16,17]. In a study conducted in a group of Australian women, Rempel found that a strong
desire to breastfeed was positively associated with breastfeeding at six months and
having no intention to breastfeed was negatively associated with breastfeeding at
six months [18].

To enhance breastfeeding promotion strategies in the context of relatively recently
changed recommendations, it is important to have a good understanding of mothers'
knowledge of the current recommendation on breastfeeding and their intention to meet
the breastfeeding recommendation. In 2008, we commenced the Healthy Beginnings Trial
(HBT) to test the effectiveness of an early childhood obesity intervention in the
first two years of life [19]. The intervention uses a home-visiting strategy to promote healthy feeding of babies
among first-time mothers. As part of this trial, we aimed to increase exclusive breastfeeding
for the first six months among participating mothers.

This paper reports on those aspects of the data collected for the HBT that were collected
at the baseline interview, prior to randomisation. We aimed, firstly, to assess first-time
mothers' awareness of the recommended duration of exclusive breastfeeding and their
intention to meet this recommendation, and, secondly, to explore the factors that
are associated with the intention to exclusively breastfeed so that appropriate breastfeeding
intervention strategies could be developed.

Methods

Study design

The design of the main study is a Randomised Controlled Trial (RCT), however for the
purpose of this analysis we have used the data collected at the study baseline, which
could be considered a cross-sectional survey. The RCT was conducted in southwest Sydney,
Australia in 2008 and approved by the Ethics Review Committee of Sydney South West
Area Health Service (RPAH Zone). The details of the HBT research protocol have been
reported elsewhere [19].

Study participants

All pregnant women who attended antenatal clinics of Liverpool and Campbelltown Hospitals
located in south-western Sydney were approached by research nurses with a letter of
invitation and information about the study. Women were eligible to participate if
they were aged 16 years and over, were expecting their first child, were between weeks
24 and 34 of pregnancy, were able to communicate in English and lived in the local
areas. Once eligibility was established and consent obtained, women then were asked
to fill in a registration form with their contact information to allow the nurses
to make further arrangements for the baseline data collection and random allocation
to study group.

From around 2700 mothers who were approached, a total of 667 first-time mothers at
24-34 weeks of pregnancy were recruited for the main study. Four hundred and nine
mothers were interviewed at their home before giving birth at the baseline and were
included in this particular study. Another 258 mothers who also participated in the
HBT were excluded, as we were not able to conduct the survey before they gave birth.

Data collection and key measures

A face-to-face interview with participating mothers was conducted by one of four research
nurses at their home, prior to randomisation. The interview lasted 20 to 30 minutes
and included a range of questions in relation to the general health, physical activity
and nutrition of the mothers, as well as demographic information.

To assess mothers' awareness of the breastfeeding recommendation and their intended
duration of exclusive breastfeeding, they were asked the following questions:

"What do you understand to be the recommended age to which you should continue to
exclusively breastfeed your child?"

"Do you plan to breastfeed your child?"

"To what age do you plan to exclusively breastfeed your child?"

In addition, the mothers were asked the main reasons for their decision to breastfeed,
or not to breastfeed with an open-ended question. The face validity of the questions
had been pilot-tested by some mothers and reviewed by breastfeeding experts in the
field.

Other study variables, including age, employment status, education level, marital
status, language spoken at home, and country of birth, were asked using the standard
questions from the NSW Health Survey [20].

Analysis

Statistical analyses were carried out using the computer package Stata 10 [21]. Relationships between study and outcome variables were examined using Pearson chi-square
tests and Mantel-Haenszel chi-square tests for trend in proportions. Two logistic
regression models were developed, one for awareness of breastfeeding recommendation
and one for intention to meet the recommendation. Variables that were significant
(P < 0.05) on bivariate analysis were entered into each model, then the least significant
terms were progressively dropped until only those with P < 0.05 and those that confounded
the effect of these variables remained in the model. Adjusted risk ratios (ARRs) with
95% confidence intervals were calculated by refitting the final models using log-binomial
regression with the Stata binreg command.

Results

The main characteristics of the participating mothers are shown in Table 1. The age range of the mothers was from 16 to 46 years with a mean age of 26 years.
Most of the mothers (87%) were either married or living with their de facto partner.
Twenty three percent had completed tertiary education and 11% spoke a language other
than English at home. In addition, 21% were unemployed and 19% had paid maternity
leave. Among those mothers who were in the workforce or studying, 11% planned to return
to work or study after giving birth within three months, and a further 21% planned
to do so within four to six months after giving birth.

Table 1. Characteristics of the 409 participating women and factors associated on bivariate
analysis with awareness of the recommendation of exclusive breastfeeding for six months
or the intention to meet the recommendations

Among all 409 participating mothers, 61% knew the recommendation of exclusive breastfeeding
for the first six months of life, and 39% either did not know or answered incorrectly.
Only 42% of all mothers intended to meet the recommendation, however 94% (384) of
the mothers did plan to initiate breastfeeding. Among the mothers who knew the recommendation,
61% intended to meet the recommendation, compared to only 11% among those mothers
who were not aware of the recommendation.

Table 1 also shows factors associated on bivariate analysis with awareness of the recommendation
of exclusive breastfeeding for six months or the intention to meet the recommendations.
Awareness of the recommendation of exclusive breastfeeding for six months was significantly
associated with older maternal age (Mantel-Haenszel χ21 = 14.9, p < 0.001), marital status (married or de facto) (χ21 = 7.9, p = 0.005), and a higher level of education (Mantel-Haenszel χ21 = 20.3, p < 0.001). Marital status and employment status of the mothers were also
found to be associated with their intention to meet the recommendation of exclusive
breastfeeding for 6 months (χ21 = 8.9, p = 0.003 and χ26 = 14.8, p = 0.02 respectively). Awareness of the recommendation was very strongly
associated with mothers' intention to breastfeed exclusively for six months (χ21 = 103.6, p < 0.001).

The only factor associated with awareness of the recommendation on multivariate analysis
was mother's level of education (Table 2). Mothers who had completed university/tertiary education were more likely to be
aware of the breastfeeding recommendation than those who had school certificate or
less, with an ARR after adjusting for the confounding effect of age of 1.45 (95% CI
1.08, 1.94, p = 0.02). More importantly, awareness of the recommendation was the only
factor that was significantly associated with the intention to exclusively breastfeed
for six months. Mothers who were aware of the recommendation were 5.6 times more likely
to intend to breastfeed exclusively to six months (after adjusting for the confounding
effect of employment status, ARR 5.61, 95% CI 3.53, 8.90, p < 0.001). Marital status
was dropped in the final model as it was not significant after adjusting for education
(p = 0.32), or after adjusting for awareness of the recommendation of exclusive breastfeeding
(p = 0.27).

Table 2. Factors associated in multivariate analysis with awareness of recommendation of exclusive
breastfeeding for six months or intention to meet the recommendation

The main reasons given by the mothers for planning to breastfeed or not breastfeed
are summarised into several themes, showing some representative examples, in Table
3. The majority of the mothers understood that breastfeeding is good for the baby's
and mother's health. For example:

Table 3. The main reasons given by the women for planning to breastfeed or not breastfeed

"Breastfeeding can help mother back to her normal weight quicker, prevent breast cancer
and boost the immune system."

"...Good for baby. God made milk special for a baby, (it's) natural, protects the
baby from illness."

Mothers who did not plan to breastfeed (6%) gave reasons for not breastfeeding such
as: "No time, have to work"; "I would be embarrassed in public" and "Can't stand the thought of it. Freaks me out."

Among the 25 mothers who did not plan to breastfeed, 21 were less than 24 years old,
10 were unemployed, only 15 completed the school certificate or less and only 9 knew
the six months exclusive breastfeeding recommendation.

Discussion

In this cross-sectional analysis we used data collected antenatally from 409 first-time
mothers participating in the Healthy Beginnings Trial in southwestern Sydney. We found
that a substantial proportion of the mothers (39%) did not know the current recommended
duration of exclusive breastfeeding, and only 41% intended to meet the recommendation
to breastfeed exclusively for six months. Awareness of the breastfeeding recommendation
was significantly associated with the mother's intention to exclusively breastfeed
her child. However, whether the intention to breastfeed is transferred to practice
remains to be tested in future research.

Breastfeeding is widely acknowledged to have health benefits for mothers and babies
[1-4]. Our study showed that most mothers were aware of some benefits of breastfeeding
for both mothers and babies and, indeed, 94% of the mothers planned to breastfeed
their child. In contrast, a small proportion of mothers who did not plan to breastfeed
(6%) had strong negative attitudes towards breastfeeding. Changing negative feelings
or negative perceptions of breastfeeding in this group of mothers is a challenge for
breastfeeding promoters, but an important one, because they face greater health risks
than the general community, being younger, less well educated and more likely to be
unemployed.

To our knowledge, to date there is no research into mothers' awareness of the WHO
breastfeeding recommendation and its association with the antenatal intention to breastfeed.
Since the intention to breastfeed is a positive predictor for actual duration of breastfeeding
[16-18], exploration of the factors influencing the intention may help health workers to
address the issues related to breastfeeding intentions. A study by Forster et al revealed
that breastfeeding intention was a strong indicator for breastfeeding initiation and
duration across all groups of Australian women, including those with less formal education,
younger women and those with less social support [16]. Therefore, focusing on mothers' intention to breastfeed may be an important strategy
to increase breastfeeding rates and duration.

The negative effects of early weaning on children and mothers remain a significant
public health concern. An analysis of data from the 2001 Australian National Health
Survey found that fewer than 50% of infants were receiving breastfeeding milk at six
months [22], which is considerably lower than the 80% figure recommended by the latest Australian
Dietary Guideline for Children and Adolescents [3,22]. In addition, very few Australian infants are being exclusively breastfed for the
recommended six months [8]. The lack of knowledge about the recommended duration of exclusive breastfeeding
among first-time mothers in our study is likely to have contributed to a reduced number
of mothers who intended to breastfeed exclusively for six months.

To date, most studies on breastfeeding awareness have focused on the health benefits
of breastfeeding and infant feeding practices [4,7,9,10]. Few studies have looked into whether mothers actually understand the recommendations
and what the recommendations mean to them. In interviews with some of the mothers
participating in our study (data not presented), we found that they had limited understanding
of the term "exclusive breastfeeding". In addition they expressed concerns about the
quantity and quality of breast milk, and whether breast milk alone would be sufficient
for their infant for six months. These findings were consistent with other studies
suggesting that the most common reason cited by mothers for stopping breastfeeding
was that the baby was unsettled, a behaviour often interpreted by mothers as indicating
an insufficient milk supply [23]. This perception of insufficient supply appears to be due to a lack of information
or lack of confidence regarding the normal process of lactation [24].

This study provides empirical evidence linking mothers' awareness of the breastfeeding
recommendations and their intention to meet the recommendation. While our study had
a relatively large sample of 409 first-time mothers, its generalisability is limited
due to the locality of the study area. Southwest Sydney is the most socially and economically
disadvantaged area of metropolitan Sydney [20]. We acknowledge the need to exercise caution in making assertions of the causal relationship
between breastfeeding awareness and the intention to breastfeed based on a cross-sectional
survey of this kind. Further studies are required to establish more definitively whether
being aware of the breastfeeding recommendations actually improves intention to breastfeed
and increases breastfeeding duration. In addition, whether model of pregnancy care
plays a role in breastfeeding awareness and intention needs to be explored further.

Conclusion

Potentially, our findings have a number of important policy implications for breastfeeding
interventions. Efforts to encourage mothers to meet the recommendations should focus
on improving mothers' knowledge and understanding of the recommendations, and address
the concerns expressed by mothers about the quantity and quality of breast milk for
the recommended duration. The effectiveness of targeted health promotion programs
needs to be tested, particularly among young, unemployed and less educated mothers.
There is a need to improve their perceptions, attitudes and knowledge, and also to
change social norms in relation to breastfeeding practices.

In addition, appropriate public health policies to help mothers to breastfeed to at
least six months, and to remove the barriers to breastfeeding, will be required to
meet the WHO recommendations. The Australian Government's proposed 18 weeks paid maternity
leave is a good start, but falls short of the required length, and falls particularly
short of some Scandinavian and European countries' maternity leave entitlements of
50 to 64 weeks. For women who need to or choose to return earlier to work, the workplace
needs to be able to provide child care and to facilitate breastfeeding on demand.
Strategies recommended in the NSW Breastfeeding Policy Directive [25] provide examples for worksites on how to promote, protect and support breastfeeding
in the community and amongst staff. These structural changes, along with health promotion
programs which include changing social attitudes to breastfeeding, may improve the
capacity of the most disadvantaged women to consider breastfeeding longer and more
exclusively.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

LMW, LB, CR and GA conceived the HBT, and contributed to the development of the trial
and the procurement of the funding.

In this study, LMW undertook literature review, data analysis and interpretation and
wrote the original draft. JS provided advice on data analysis. LB, CR, GA and JS made
significant comments on the draft. All authors have read and approved the final manuscript.

Acknowledgements

This is part of the Healthy Beginnings Trial funded by the Australian National Health
and Medical Research Council (ID number: 393112). We sincerely thank the Associate
Investigators, Prof. Anita Bundy, Dr Lynn Kemp and Dr Vicki Flood and the members
of the steering committee and working group for their advice and support. We wish
to thank all the families for their participation in this study. We also thank members
of the project team including Karen Wardle, Carol Davidson; Cynthia Holbeck; Dean
Murphy; Lynne Ireland, Brooke Dailey, Kim Caines and Angela Balafas. In addition,
we wish to thank James Kite, and Therese Carroll for their support in setting up the
database and Hui Lan Xu for assisting data entry and analysis.

National Health and Medical Research Council: Dietary Guidelines for Children and Adolescents in Australia: Incorporating the Infant
Feeding Guidelines for Health Workers. Canberra, Australia: Commonwealth Department of Health and Ageing; 2003.